HER2+ Early-Stage Breast Cancer Roundtable: Counseling Patients to Understand Their Diagnosis
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Dr Maryam Lustberg: So I'll highlight maybe some of the questions that my patient really struggled with. One was that she wasn't expecting to have developed breast cancer. So she wanted to know what was it in terms of what she might have done that caused her to have this. So, I think I've spent a lot of time reassuring her that breast cancer is so common that even in an average-risk woman, 1 in 8 women in the US can develop breast cancer. The main risk factor is really being a woman and advancing in age. Certainly, there could be a family history and genetic factors, but those are not the most common presentation.
She did have some evidence of higher breast density. So that was one risk factor that we could see in terms of reviewing some of her older imaging, although she wasn't the most up to date on imaging. But I'm just curious to hear how you guys counsel patients that you see with this similar presentation on potential risk factors that may have led to this. Do you spend a lot of time talking about risk factors, or do you feel that, well, they've already developed the breast cancer, let's focus more on the path forward?
Dr Giancarlo Moscol: The way how I address that usually is by explaining, first of all, we don't know why breast cancer happens. We know, as you're saying that it's a disease that tends to be acquired and increase in incidence as women get older. Genetics and germline mutation would only explain 5% to 10% of that, and that's very important because by the moment they come to clinic, I don't know why, but the expectation is that everybody thinks that they're going to have an underlying mutation even though they don't have a clear family history.
So I usually like to go over the family history and I explain there are some risk factors that have been associated with an increased risk, but that doesn't mean that we know that exactly they led to breast cancer. Causation and correlation are different. I do believe that there is an increased awareness about the role of family history, and I tend to test the majority of my patients for underlying mutation just to make sure that we have covered all grounds. But at the end of the day, I tell them most likely, we'll never really know what happened there, and we can try to modify the factors moving forward to prevent this from being a problem to you.
Dr Ting Bao: I also try to reassure them it's really not their fault that they have breast cancer and just unfortunately, lots of times it's bad luck. Yeah, I agree. Sometimes it's not hereditary. It's not because someone in the family has breast cancer. Lifestyle—that's the question they always ask. But mainly because I'm also integrative medicine physician, so the stress increases risk of breast cancer. Insomnia, not able to sleep for years, increased risk of breast cancer. So my answer is usually we don't know for sure, but on the other hand, the stress and not sleeping well does not help. So if there's a way we can potentially improve their lifestyle, I would strongly recommend that.
Dr William Gradishar: Yeah. I would echo many of the things that have been said. It is the most common question we get asked, "Why did I get this?" And I also reassure them that for the vast majority, there isn't a clear etiology that we can assign to why they got breast cancer. We have the long list of potential things that can contribute, and then patients often abruptly want to change to extremes. "I'm never drinking alcohol again." "I'm only going to eat organic." And many of those things, as you pointed out, are healthy generally for a good lifestyle. But to suggest that all of those things are going to impact on risk or risk of recurrence, you might be miserable for the rest of your life eating carrots, I don't know. So you have to find balance in what you recommend to patients.
Dr Maryam Lustberg: So true. And some of those more drastic lifestyle changes, if they're undergoing chemotherapy, as you all know, it's many times not the right time to be starting a lot of these changes. But certainly as treatment is winding down, I think survivorship care as a specialty is where we can use that as that teachable moment to kind of focus on healthier lifestyle and those modifiable risk factors that all of you have talked about. Yeah, I completely agree.
Dr Giancarlo Moscol: The key also has to be sustainability over time, right? I always tell them, "You don't want to go into a very strong restrictive diet and you're going to abandon it after 10 days. That's not the point here. So it's better to introduce small changes that you can keep in the long term to you and your family."
Dr Ting Bao: But exercise is always good.
Dr Giancarlo Moscol: Oh yes.
Dr Ting Bao: I recommend everyone to exercise at least half an hour per day. Yeah, moderate exercise.
Dr Maryam Lustberg: Increasing movement of any type.
Dr William Gradishar: Walking around ASCO.
Dr Maryam Lustberg: Yes. I get it.
Dr Ting Bao: Totally.
Dr Giancarlo Moscol: Yeah, because you have your Fitbit there. And checking your steps is important.
Dr Maryam Lustberg: Yes.
Dr William Gradishar: But I did want to make one comment about the genetic testing just to add onto what you said, because obviously it accounts for a very small fraction of patients that we can assign that etiology to why they got breast cancer. But as we all appreciate, the guidelines are changing about who we should be testing and it really is because we now have therapeutics. We're not discussing that today. So I think the number of patients we're probably testing is growing and we might find unexpected mutations that, in the patient that's appropriate, may be able to get certain kinds of therapy.
Dr Maryam Lustberg: Yes. Yeah, I completely agree. In terms of, we have had several studies looking at if we use the older NCCN guidelines and only test those patients, we're actually going to miss some proportion of patients. Yes. So I think as cost of genetic testing has continued to come down, I think it's much readily available for sure.
Dr William Gradishar: The criteria for doing genetic testing have been refined year after year. There are different organizations that have guidelines, some who say everybody should get tested. But I think basically it's dependent, in a general sense, on family history, the age of the patient when they get the diagnosis, whether other immediate or close family members have specific diagnoses of cancer in their family. So the list of things that would push you towards getting genetic testing, the threshold for doing it hasn't been lowered, because we have a greater understanding of who might harbor, say a BRCA1 or 2 mutation as well as some of the less common ones. And by extension, if you knew that, not only is it important for family history and other members of the family, but in a high-risk patient or in somebody with advanced disease, there's a specific group of drugs that we use as a potential therapy in these patients.
Dr Maryam Lustberg: I think intuitively, it makes sense to me if a patient is not familiar with breast cancer treatment paradigms, I think it's very normal for them to wonder, "Why aren't we going to surgery first? Why are we doing some type of preoperative treatment first?" I think a lot of our discussion was, "Why can't you just cut this out? Why are we spending months and months doing some type of preoperative treatment?" So I think part of my role as a medical oncologist was to really spend time explaining the biology of HER2-positive breast cancer, why it actually can be really beneficial, and why this has become the standard of care to do this type of preoperative regimen. I would love to hear your thoughts in terms of how you explain that concept to patients and other strategies to make it a little bit more comprehensible. Anybody can chime in.
Dr Giancarlo Moscol: Well, I will tell you, what I found is very useful. I actually have a printout where I share information about the natural history of the breast cancer, what staging means, how you expect the cancer cells to move from the breast primary to the auxiliary lymph nodes, level 2, level 3, and 3, et cetera. Then I go through the receptors and I explain that in the past, HER2 unfortunately was linked with a worse prognosis. It usually means that the cancer is more aggressive, has high-grade disease, and a high rate of proliferation, but now we have actually extremely effective treatments to the point that now having HER2 positivity has become a good prognostic feature. That's something that I have to underline with the patients.
I tell them that in this type of situation, it's better to make sure that we use all the tools that we have available and all the treatments in order to get the best response possible. Because it's not only going to help the surgeon minimize and get better surgical outcomes, but also improve the likelihood of the cancer not coming back locally and distally. So if we have the tools and we can effectively prove that the cancer is sensitive to the treatment, it will be much better to run the test before surgery. It's true that you can always proceed on some exceptions with upfront surgery at the beginning, but whenever a patient has a positive lymph node or if the mass is bigger than three centimeters, I highly discourage that approach.
Dr Ting Bao: Yeah. I usually talk about there are different kind of breast cancer treatment. Surgery, radiation are usually local treatment and then chemo and HER2 agents and hormonal treatment as systemic treatment. So it's kind of treat the whole body. Then the fact it's already in the lymph nodes suggests possibly already there's some cancer cells in the body. Therefore, we should properly start with a systemic treatment to prevent it from spreading further. And then to local treatment after we shrink it.
Dr William Gradishar: But at the root of your question too is that we all encounter patients who have different levels of anxiety crossing the threshold of our door, and they have different, I don't know how to put it, maybe intellectual capacity to appreciate all the things we talk about. So there's a couple of things that are working when we talk to patients is, one, we have to talk at their level so that they actually understand some of the things that we've been talking about. Because we can talk about staging and systemic spread and all that, but sometimes depending on the patient, they don't actually get it. And we all encounter patients who can be as smart as anybody, but they're so scared that they don't hear a thing, and you often have to return to that same discussion or rely on whoever they bring with them to help be the scribe for the discussion.
Dr Maryam Lustberg: Yes. Those are such good points. I think the idea that this amount of information can really be imparted in one clinic session, often it's multiple discussions that I know all of us do as oncologists, and I think making sure that the way we're presenting the information is comprehensible is such an important point that you made.